CHILD HISTORY FORM- CAMP - LLA Therapy



LLA THERAPY CHILD HISTORY FORM FOR CAMPS

GENERAL INFORMATION

Child’s Name:______________________________________________________Age:____________________________

Name by which your child is called: ____________________________________Date of Birth:_____________________

Pediatrician: _____________________Diagnosis:_______________________ Referred by:________________________

Briefly describe your child’s problems:___________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Briefly describe your child’s strengths:___________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The child lives with:__________________________________________________________________________________

Names of siblings/ages:_______________________________________________________________________________

MEDICAL HISTORY

The child’s current health is (Good (Fair (Poor

Please list all current medications being taken by your child:

Medication Dosage Reasons for medication

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any allergies (medicine, food, environmental):

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SPEECH-LANGUAGE

Does your child:

Answer when you talk to him/her? οSometimes οYes οNo

Talk about what he/she is doing? οSometimes οYes οNo

Have trouble pronouncing words? οSometimes οYes οNo

Hesitate, repeat or stutter words? οSometimes οYes οNo

Can your family understand your child’s speech? οSometimes οYes οNo

Can people outside your family understand your child? οSometimes οYes οNo

When you talk to your child, how much does he/she understand? Check all that apply.

οA few words οSimple directions οQuestions

οMany words/phrases οComplex directions οAlmost everything I say

How does your child usually let you know what he/she wants? Check all that apply.

οPoints to objects οUses sign language οMakes a few sounds οUses gestures

οGrunts οUses a few words οUses 2-3 word phrases οUses sentences

What does your child like to talk about?__________________________________________________________________

__________________________________________________________________________________________________

OCCUPATIONAL THERAPY SKILLS

Does your child have an established hand dominance? Yes: Left Right No

Does your child use writing tools successfully? Yes No

Does your child cut with scissors? Yes No

Is your child resistive to different textures like glue, paint, etc? Yes No

How much assistance is needed with grooming tasks? None Minimal Totally Dependent

How much assistance is needed with dressing tasks? None Minimal Totally Dependent

SOCIAL-EMOTIONAL:

How does your child get along with other children?________________________________________________________

Does your child prefer to play alone or with other children?__________________________________________________

Does your child seem overly sensitive to criticism? (Yes (No

Does your child seem overly anxious or fearful? (Yes (No

Does your child tend to be quiet or withdrawn? (Yes (No

Does your child tend to be easily frustrated? (Yes (No

Does your child tend to be unusually uncooperative or stubborn? (Yes (No

Does your child have temper tantrums or outburst of anger? (Yes (No

ORGANIZATION:

Does your child frequently lose things (i.e. homework, coat)? (Yes (No

Does your child have difficulty tolerating changes in plans? (Yes (No

Does your child need extra assistance to get started with a task? (Yes (No

Does your child become easily distracted while working/playing? (Yes (No

Does your child have a short attention span? (Yes (No

EDUCATIONAL HISTORY

Is your child enrolled in school or pre-school? (Yes (No (if no, skip this section.)

Name of school or pre-school:__________________________________________________________________________

Grade:__________________

How does your child do in school?______________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Does your child receive any special education services? (Yes (No

|Special Education Services |Frequency (times per week) |Duration (minutes) |

|Speech-Language Therapy | | |

|Occupational Therapy | | |

|Physical Therapy | | |

|Guidance Services | | |

|LD Support Services | | |

|DH Support Services | | |

|Other: | | |

SOCIAL WORK INFORMATION

Are there any community agencies active with your child? (Yes (No

Agency name:_______________________________________________________________________________________

THERAPY HISTORY

Has you child been previously tested for therapy services? (Yes (No

If yes, where and when?________________________________________________________.

Does your child currently receive therapy services elsewhere? (Yes (No

If yes, where and when?________________________________________________________ If no, skip this section

Therapy received:

(Physical Therapy Frequency______________

(Occupational Therapy Frequency______________

(Speech Therapy Frequency______________

(Other Frequency______________

ACTIVITY INFORMATION

Describe interests, play activities and toys that your child likes best: ____________________________________________________________________________________________________________________________________________________________________________________________________

SOCIAL GROUP QUESTIONS:

Childs likes and dislikes:______________________________________________________________________________

Please answer yes or no to the following questions:

Able to greet and say goodbye appropriately (Yes (No

Makes eye contact (Yes (No

Keeps appropriate distance from people during conversation (not to far or to close) (Yes (No

Is polite (please, thank you etc) (Yes (No

Asks appropriate questions (Yes (No

Answers questions appropriately (Yes (No

Initiates conversation or a new topic (Yes (No

Stays on topic (Yes (No

Plays well with adults (Yes (No

Plays well with peers (Yes (No

Shy (Yes (No

Interrupts (Yes (No

Speaks to loud (Yes (No

Shares easily (yes (No

Impatient (Yes (No

Takes turns during conversation (yes (No

Takes turns during games/play (Yes (No

Follows the rules of games/play (Yes (No

Difficulty showing emotions or talking about them (Yes (No

Please remember to include any additional information (IEP, ETR, Progress Reports, etc.)

Name of the person completing this history and relationship to child: _________________________________________

Date:______________________________ Thank you for taking to time to complete this form.

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